Return to Play After Soleus Muscle Injuries
Return to Play After Soleus Muscle Injuries
Carles Pedret,*†‡§ MD, PhD, Gil Rodas,||{ MD, PhD, Ramon Balius,‡# MD, PhD,
Lluis Capdevila,** MD, PhD, Mireia Bossy,‡§ MD, Robin W.M. Vernooij,†† MD,
and Xavier Alomar,§ MD, PhD
Investigation performed at Sports Catalan Council, Barcelona, Spain
Background: Soleus muscle injuries are common in different sports disciplines. The time required for recovery is often difficult to predict,
and reinjury is common. The length of recovery time might be influenced by different variables, such as the involved part of the muscle.
Hypothesis: Injuries in the central aponeurosis have a worse prognosis than injuries of the lateral or medial aponeurosis as well as
myofascial injuries.
Study Design: Case series; Level of evidence, 4.
Methods: A total of 61 high-level or professional athletes from several sports disciplines (soccer, tennis, track and field, basketball,
triathlon, and field hockey) were reviewed prospectively to determine the recovery time for soleus muscle injuries. Clinical and
magnetic resonance imaging evaluation was performed on 44 soleus muscle injuries. The association between the different
characteristics of the 5 typical muscle sites, including the anterior and posterior myofascial and the lateral, central, and medial
aponeurosis disruption, as well as the injury recovery time, were determined. Recovery time was correlated with age, sport, extent
of edema, volume, cross-sectional area, and retraction extension or gap.
Results: Of the 44 patients with muscle injuries who were analyzed, there were 32 (72.7%) strains affecting the myotendinous
junction (MT) and 12 (23.7%) strains of the myofascial junction. There were 13 injuries involving the myotendinous medial (MTM),
7 affecting the MT central (MTC), 12 the MT lateral (MTL), 8 the myofascial anterior (MFA), and 4 the myofascial posterior (MFP). The
median recovery time (±SD) for all injuries was 29.1 ± 18.8 days. There were no statistically significant differences between the
myotendinous and myofascial injuries regarding recovery time. The site with the worst prognosis was the MTC aponeurosis, with a
mean recovery time of 44.3 ± 23.0 days. The site with the best prognosis was the MTL, with a mean recovery time of 19.2 ± 13.5 days
(P < .05). There was a statistically significant correlation between recovery time and age (P < .001) and between recovery time and the
extent of retraction (P < .05).
Conclusion: Wide variation exists among the different types of soleus injuries and the corresponding recovery time for return to the
same level of competitive sports. Injuries in the central aponeurosis have a significantly longer recovery time than do injuries in the
lateral and medial aponeurosis and myofascial sites.
Keywords: soleus muscle; myofascial; myotendinous; central tendon; return to play
The soleus muscle is located in the posterior aspect of the
calf and within the posterior leg fascia. It has medial and
lateral intramuscular aponeuroses arising from its anterior
wall of the epimysium that are directed distally into the
muscular body.4,12,32 An intramuscular tendon is located
in the central part of the muscle and contributes to the formation of the Achilles tendon.31
This multipennate musculotendinous structure is
affected by any injury to its complex musculotendinous
junctions.8,17-19 Injuries in the soleus muscle have a
varied topography according to the affected musculotendinous union, which has been described recently by
Balius et al.2 A recent study identified 5 sites in the
soleus muscle where lesions potentially might be located:
the musculotendinous junction sites (proximal medial
strains, proximal lateral strains, and distal central tendon strains) and myofascial sites (anterior strains and
posterior strains).2
*Address correspondence to Carles Pedret, MD, PhD, Sports Medicine and Imaging Department, Clinica Mapfre de Medicina del Tenis,
C/Muntaner 40, 08011 Barcelona, Spain (email: ).
†
Clı́nica Mapfre de Medicina del Tenis, Barcelona, Spain.
‡
Clı́nica CMI Diagonal, Barcelona, Spain.
§
Clı́nica Creu Blanca, Barcelona, Spain.
||
Medical Services, Futbol Club Barcelona, Ciutat Esportiva Futbol
Club Barcelona, Barcelona, Spain.
{
Leitat Foundation, Leitat Technological Center, Terrassa, Spain.
#
Sport Catalan Council, Generalitat de Catalunya, Barcelona, Spain.
**Health & Sport Lab, Eureka Building, PRUAB, Autonomous University of Barcelona, Barcelona, Spain.
††
Iberoamerican Cochrane Centre, Biomedical Research Institute
Sant Pau (IIB Sant Pau), Barcelona, Spain.
One or more of the authors has declared the following potential conflict
of interest or financial support: Personal and financial support for this study
was received from the Spanish Society for Sports Traumatology (SETRADE).
The Orthopaedic Journal of Sports Medicine, 3(7), 2325967115595802
DOI: 10.1177/2325967115595802
ª The Author(s) 2015
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/
licenses/by-nc-nd/3.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For reprints and permission queries, please visit SAGE’s Web site
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Pedret et al
The Orthopaedic Journal of Sports Medicine
Muscle injuries are the most common sports injuries.
They are characterized by a variable interval in which the
athletes are not able to train or participate in competition.14,15 This variation in time might be the result of a lack
of specific rehabilitation protocols or guidelines to standardize the treatment of muscle injuries24,26 as well as other
variants. In addition, many muscle injuries are misdiagnosed and have an insidious evolution, and athletes often
have a high risk of reinjury.14 Calf injuries are very common in sporting populations, specifically soleus muscle
injuries.
The concept of return to play (RTP) refers to the time
an athlete can return to normal sports activity with a
minimum risk of reinjury.9,13,21,25 The soleus muscle is
integrated into the triceps surae complex (formed by the
gastrocnemius and the soleus muscles), which is the muscle
group that experiences the highest number of injuries after
the hamstrings, quadriceps, and hip adductors.15 Soleus
muscle injuries are more frequent in older athletes.7 The
soleus muscle consists predominantly of slow fibers that
are occasionally exposed to explosive movements. Furthermore, an injury in the soleus muscle may be underestimated and thought not to be clinically important. The
diagnosis of these injuries is often delayed because ultrasound is frequently negative, and only magnetic resonance imaging (MRI) can confirm the diagnosis.5
The aim of this study was to assess whether (...truncated)
